OBSERVATIONS - August 11, 2008
Low-Cost, High-Quality Health Care in America - How Do They Do That?
Four of the nation’s better known health care improvement experts, Drs. Atul Gawande, Elliott Fisher, Donald Berwick, and Mark McClellan, invited a select group of health care delivery system leaders to provide input at a July 21 Washington meeting into the ongoing discussion about delivery system reform as part of national health care reform. The invited leaders represented major health care organizations from 10 of the highest quality, lowest cost regions from among the nation’s 306 Health Referral Regions, based on data drawn from The Dartmouth Atlas, the CMS Hospital Compare Survey, and the Hospital Consumer Assessment of Healthcare Provider and Systems (HCAHPS) survey, as well as geographic, demographic and institutional diversity criteria. The regions included Asheville, N.C.; Cedar Rapids, IA; Everett, WA.; La Crosse, WI.; Portland, ME.; Richmond, VA.; Sacramento, CA.; Sayre, PA.; Tallahassee, FL.; and Temple, TX.
Not surprisingly, among the 40-50 organizations represented were many group practice-based integrated delivery systems, including the Scott and White Clinic in Temple, TX., the Everett Clinic in Everett, WA., the Franciscan/Skemp-Mayo Health System and the Gunderson-Lutheran Health Care System in La Crosse, WI., Kaiser Permanente and the Sutter Health Care System from Sacramento, CA., and the Guthrie Clinic Health Care System in Sayre, PA.
Over a series of panel discussions, the high performance system leaders were asked to respond to the following three intriguing questions:
- “How did you get to be a high quality, low cost community?”
- “What is the structure for accountability and coordination of care (particularly for patients receiving both inpatient and outpatient care)?”, and
- “What mechanisms are used to reduce overtreatment and undertreatment (e.g., altered financial incentives, peer review, support for collaboration, and utilization measurement)?”
While the detailed responses from many of the participants were well worth closer attention, the general conclusions, as later summarized for invited guests and the media by Dr. Gawande, seem particularly relevant – if not often enough emphasized – in the ongoing health care reform debate:
- In general, those communities with high performing health care organizations seem to have a “culture of collaboration” among providers, and in many cases even among competitors, directed at improving health care in the public interest. In the Sacramento area, which was represented by four large competing systems, including Kaiser Permanente, he likened this culture to “golf competition” rather than “all out war”.
- Similarly, these health care communities seemed to manifest a “culture of constraint” with respect to seeking financial gain at the expense of other values useful to the community.
- The institutions in these communities fostered “physician engagement,” and particularly encouraged physician leadership. There was recognition by all elements in the community that the physician’s pen was often the driving force in determining the cost and quality of care for the community.
- Most of the selected high performance regions had one or more institutions that were prominent examples of successful physician-hospital integration.
- Many of the institutions had found one or more ways to “blunt the effect” of fee-for-service reimbursement of providers.
- Systematic measurement of performance was manifest in many of the institutions.
- Some of the communities demonstrated one or more examples of cooperative partnerships with employers.
- Many of the institutions were concerned about potential external threats to their continuing success. These included: a failure of health care reform to reinforce their successful models -- or, worse, undermine them; uncertainty about the enforcement of antitrust and other regulations that can inhibit integration activities; concern that consumers in other geographies may not be ready for or understand the idea of “systems of care;” and worries about the adequacy of the future provider workforce, especially in primary care.
The lesson for other communities across the country, as Gawande said, is: “It can be done!” Unanswered was the related question of whether there is anything in the health reform plans emerging from Congress that would help get it done.
- Jay Crosson, MD, Senior Fellow, KP-IHP
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